804 



ABNORMAL CONDITIONS OF THE HIP-JOINT. 



upper and back part of the acetabulum. The 

 crepitus and frequent recurrence of the dis- 

 placement rendered it sufficiently obvious that 

 the brim of the acetabulum had been broken 

 in the above-mentioned situation. The bone 

 was a third time restored to its place, and a 

 strong band placed around the pelvis. In 1836, 

 I admitted the man into the Richmond Hos- 

 pital. He was at this time unable to walk 

 without the assistance of a crutch. The in- 

 jured limb was one inch and a half shorter than 

 the other. When standing, he rested it upon 

 the points of the toes, the heel being drawn 

 upwards ; but a slight degree of extension was 

 sufficient to restore it to its natural length ; and 

 when the man was lying in bed there was 

 hardly any difference perceptible in the length 

 of the two limbs. The breadth of the injured 

 hip was occasionally greater than that of the 

 sound one, and the head of the femur could be 

 pushed upwards easily, and, of course, it al- 

 ways ascended, when the patient endeavoured 

 to support his weight upon it; and in many 

 motions of the joint, the rubbing together of the 

 broken surfaces was distinctly audible. 



After having remained in the Richmond 

 Hospital under our observation for two months, 

 he was discharged. Nothing could be devised 

 to make his limb more useful to him. The 

 fracture, therefore, of the supercilium of the ace- 

 tabulum is a very serious injury, which it be- 

 hoves surgeons to be well acquainted with. A 

 successful mode of managing such cases has 

 not yet been exemplified.* 



2. Fracture of the superior extremity of the 

 femur. The head of the femur is so protected 

 by the acetabulum, that it is seldom or never 

 fractured, except by gunshot injuries. The 

 neck and rest of its superior extremity are, 

 however, we find, subjected to various accidents. 

 The general symptoms of fractures of the neck 

 and upper extremity of the femur are, that the 

 affected limb is shorter than the other, the heel 

 rises to the ievel of the opposite malleolus, the 

 patella, leg, and foot seem much everted ; there 

 is a flattening of the natis, and a fulness of the 

 groin. The patient does not attempt to stand, 

 much less to walk. There is in the part itself, 

 as it were, a conscious inability to support the 

 weight of the body, and even when the patient 

 is lying on a horizontal plane, as in bed, we 

 ,n'nd that he cannot, by the unassisted effort of 

 the muscles of the injured limb, elevate it from 

 the horizontal level, upon which it lies power- 

 less. When the surgeon, standing at the foot 

 of the bed, seizes the affected limb, and pulls 

 it towards him, so as gradually to overcome the 

 contractile power of the muscles, the limb is 

 restored to its natural length, and if now we 

 resort to the painful expedient of rotating the 

 thigh, crepitus is rendered manifest. When- 

 ever the surgeon relaxes the force by which the 

 limb was restored to its natural length, the 

 shortening, eversion, and deformity of the limb 



* In the twelfth volume of the Dublin Medical 

 Journal, Mr. R. Smith has made some valuable 

 observations on this case, in relation to the diag- 

 nosis of obscure cases of injury of the hip and 

 --!i*mlder-jnints. 



recur. Such are the general signs of fracture 

 of the upper extremity of the thigh-bone. 

 The portion of the bone, called the neck, may 

 be fractured transversely with respect to the 

 direction of its long axis, either within or with- 

 out the capsular ligament. The first is deno- 

 minated the intra-capsular fracture, the second 

 the extra-capsular fracture. Oblique fractures 

 of the neck of the bone are not impossible. 



A. Intra-capsular fracture of the neck of 

 the femur. This fracture has been seldom 

 seen in the young subject, but is one of the 

 most common accidents to which elderly peo- 

 ple are liable. In such persons many cir- 

 cumstances in their organization appear to ac- 

 count for their great liability to this accident. 

 Their muscles have lost their firmness, and are 

 more or less in a state of atrophy ; the trochan- 

 ter major becomes peculiarly prominent; the 

 neck of the femur yielding somewhat, perhaps, 

 to the weight of the body, descends and loses 

 some of its obliquity. This atrophy of the 

 muscles and bones is not so frequently noticed 

 in the male as in the elderly female, in whom 

 the breadth of the pelvis is greater and the tro- 

 chanter major more projecting. These obser- 

 vations account sufficiently for the great liability 

 to the intra-capsular fracture, which we notice 

 in the elderly subject, and for the more fre- 

 quent occurrence of the accident in the aged 

 female than in the male. In the young subject 

 the trochanter major does not project so much, 

 the muscles surrounding the hip-joint are re- 

 markably firm, and when falls on the side 

 occur, the surrounding muscles and the os in- 

 nominaturn share, with the great trochanter, the 

 weight of the fall. The bone in the young 

 subject is better calculated from its form and 

 its organization to resist the effects of falls on 

 the trochanter, and in these fractures of the 

 neck of the femur have been rarely witnessed. 

 In the young subject, too, the neck of the 

 femur is comparatively shorter than in the aged, 

 the angle of union of the neck with the shaft of 

 the bone is more open, and the axes of both 

 neck and shaft are more in a line. The great 

 proportion of animal matter existing in the 

 bones of the young, and consequent elasticity 

 of the bone, render it capable of resisting frac- 

 ture, while, on the contrary, the comparative 

 deficiency of animal matter, arid the consequent 

 redundancy of earthy material in the aged sub- 

 ject, render the neck of the femur friable. In 

 a word, the tissue of the bones in general does 

 not escape, in the aged, that atrophy which 

 affects the rest of the system, and when we re- 

 collect the functions which the neck of the 

 thigh-bone has to perform, we shall not be sur- 

 prised to learn that the effects of this atrophy 

 are more readily felt and seen in this part of 

 the osseous system than perhaps any other. 

 The superincumbent weight of the body and 

 the action of muscles must have a tendency to 

 diminish the obliquity of the neck of the thigh- 

 bone, to render it more horizontal, and conse- 

 quently less capable of bearing up against the 

 effects of concussion. 



Besides the loss of obliquity of the neck of 

 the thigh-lwne, we find two othor c;irrumst;iu- 



